Report on Surveillance for Lyme Disease: 2016 May 2017 In 2016, 174 cases of Lyme disease Active surveillance carried out in 2016 made it possible to collect were reported to public health 1 036 Ixodes scapularis ticks of which 82 were positive for authorities, including 124 cases that Borrelia burgdorferi: they were spread over 22 sites mostly located in were acquired in Québec. Montérégie. Active surveillance identified four new endemic municipalities for Lyme disease in Estrie, Mauricie et Centre-du-Québec, Outaouais and The Laboratoire de santé publique du Montérégie. Québec received 2 158 Ixodes scapularis ticks from Human surveillance Québec, primarily from the regions of Estrie, Mauricie et Centre-du- Lyme disease is a reportable disease (MADO) in Québec since Québec, Montréal, Laurentides, November 2003. Human surveillance of this disease is based on reports by Lanaudière, Montérégie and the physicians and laboratories, as well as on epidemiological investigation Capitale-Nationale. More than 17% of conducted by public health authorities. these ticks were positive for Borrelia burgdorferi. In 2016, 174 cases (113 confirmed and 61 probable)1 of Lyme disease were reported to the public health authorities of Québec. Of these, 124 (71%) were acquired in Québec, 42 (24%) infected outside of Québec, and the Summary probable acquisition location was unknown for eight cases. The number of reported cases and particularly the number of cases acquired in Québec Human surveillance 1 has been increasing since the definition of “probable case” was added to the nosological definition of Lyme disease in 2011 (Figure 1). This increase Acarological surveillance 3 could be explained by increased exposure to Lyme disease in Québec or by Other diseases transmitted by greater awareness of this disease by health professionals. 6 Ixodes scapularis Limitations 8 1 The definitions of “confirmed case” and “probable case” for Lyme disease can be found in the glossary of nosological definitions from the Ministère de la Santé et des Services sociaux du Québec at the following address: http://publications.msss.gouv.qc.ca/msss/document-000480/. Report on Surveillance for Lyme Disease: 2016 2 Figure 1 Evolution of the number of Lyme Health regions of infection acquisition disease cases reported in Québec In 2016 the geographical distribution of cases acquired from 2004 to 2016 according to the in Québec was essentially limited to Estrie (n = 76, 61%) place of infection acquisition and Montérégie (n = 38, 31%), with respective incidence rates of 23.5 and 2.5/100 000 person-years (PY) 200 Unknown Outside of Québec Acquired in Québec (Table 1). Two cases were acquired either in Estrie or in 180 Montérégie, one case was acquired in Mauricie et 160 Centre-du-Québec, and a first case was acquired on the 140 42 Côte-Nord. The health region of acquisition was 41 120 unknown for the six remaining cases. 70 100 54 The high incidence observed in Estrie can be explained 80 by the fact that 62/76 (82%) of the cases acquired in this 60 124 Cases Number 113 region occurred in two areas of the local services 40 networks (réseaux locaux de services or RLS) of 72 66 25 Pommeraie and Haute-Yamaska. These areas were 20 23 11 9 8 16 0 2 8 61 7 2 4 2 5 transferred from Montérégie to Estrie as the Centre intégré universitaire de santé et de services sociaux de l’Estrie – Centre hospitalier universitaire de Sherbrooke Source: The number of cases reported between 2004 and 2015 come was created in April 2015. These two areas have several from Flash Vigie, July 2016, and the number of cases in municipalities that are endemic for Lyme disease2 on 2016 is extracted from the MADO file (Bureau de surveillance their territory. et de vigie, Infocentre du Québec, INSPQ) retrieved on February 24, 2017. Table 1 Number of cases of Lyme disease and Among the 124 cases acquired in Québec, 90 (73%) incidence rate according to the were reported between the months of July and probable infection acquisition health September, with the peak observed in September region, Québec, 2016, n = 124 (n = 37) (Figure 2). Number Number of of Incidence probable Figure 2 Number of cases of Lyme disease confirmed rate/100 000 Health region cases contracted in Québec according to the cases person- (%) years month and date reported, 2016, n = 124 (%) Mauricie et 40 37 Centre-du- 1 (1) 0 0.4 35 31 Québec 30 Estrie 51 (67) 25 (52) 23.5 22 25 Montérégie 19 (25) 19 (40) 2.5 20 13 Estrie or 15 1 (1) 1 (2) - 9 Montérégie Cases Number 10 3 3 Côte-Nord 0 1 (2) 1.1 5 2 2 2 0 Unknown 4 (5) 2 (4) - Total 76 (100) 48 (100) 1.5 Population estimates used for the incidence rate are drawn from the Institut de la statistique du Québec (2016). Source: Bureau de surveillance et de vigie, Infocentre du Québec, Source: Bureau de surveillance et de vigie, Infocentre du Québec, INSPQ, MADO extraction as of February 24, 2017. INSPQ, MADO extraction as of February 24, 2017. 2 In 2016 the endemic municipalities for Lyme disease were those where the risk of infection after a tick bite was moderate or high. The list of these municipalities can be found on the INSPQ (2016a) website. Report on Surveillance for Lyme Disease: 2016 3 Characteristics of cases acquired in Québec 2014, of which 48% (n = 2 028) and 55% (n = 2 549) Among the 124 cases of Lyme disease acquired in were I. scapularis (INSPQ, 2016b and c). Québec, 57% were men and 43% were women with Table 3 shows the characteristics of the I. scapularis respective crude incidence rate of 1.7 and of acquired in Québec in 2016 and for which the health 1.3/100 000 person-years. The average age of cases region of origin is known. These ticks came from was 43 years (median age: 49 years, minimum age: 16 regions and the I. scapularis ticks were essentially 1 year, and maximum age: 84 years). The most affected adults and nymphs.4 age group was 60–69 years with an incidence rate of 2.9/100 000 person-years (Table 2). Human-origin ticks Table 2 Number of cases of Lyme disease In Montérégie, unlike the other regions, most of the ticks contracted in Québec and crude submitted were of human origin because animal incidence rate by sex and age group, surveillance was stopped in that region in 2009. 2016, n = 124 Furthermore, in the summer of 2014, the Direction de la santé publique of this region asked four local services Incidence rate networks5 to cease sending ticks of human origin, as the Number of /100 000 person- cases (%) risk of tick exposure in their areas was considered years sufficiently high that it was no longer needed to be Sex demonstrated by passive surveillance (INSPQ, 2016c). Male 71 (57) 1.7 This measure considerably reduced the total number of Female 53 (43) 1.3 ticks of human origin submitted since 2015 (n = 368) Age in years compared to 2013 (n = 430 ticks) and < 20 years 26 (21) 1.5 2014 (n = 505 ticks) (INSPQ, 2016b and d). 20–39 years 21 (17) 1.0 40–49 years 18 (15) 1.7 Animal-origin ticks 50–59 years 20 (16) 1.6 60–69 years 30 (24) 2.9 The health regions that submitted the most animal-origin 70 years 9 (7) 0.9 ticks were Montréal, Laurentides, Mauricie et Centre-du- Source : Bureau de surveillance et de vigie, Infocentre du Québec, Québec, Lanaudière, Capitale-Nationale and Estrie ≥ INSPQ, MADO extraction as of February 24, 2017. (Table 3). Acarological surveillance Ticks stage Although the number of I. scapularis ticks submitted in Acarological surveillance related to Lyme disease 2015 was similar to that of previous years, more nymphs combines active and passive surveillance of the (n = 37) were submitted that year than in 2015 (n = 29) Ixodes scapularis (I. scapularis) tick. and in 2014 (n = 21). Most of the nymphs submitted in 2016 came from the same regions as those submitted in Passive surveillance 2015 (Mauricie et Centre-du-Québec, Estrie, Montréal, Outaouais and Montérégie). Four other nymphs came As part of the passive surveillance program, the from Laurentides, Lanaudière and Côte-Nord. Laboratoire de santé publique du Québec (LSPQ) 3 received 4 402 ticks, of which 60% (n = 2 627) were I. scapularis acquired in Québec. In comparison, the LSPQ received 4 272 ticks in 2015 and 4 617 ticks in 3 This number excludes I. scapularis ticks when the person who was bitten or the owner of the bitten animal had travelled outside of Québec in the two weeks prior to tick removal. Ticks were also excluded when it was not known where the bitten person or animal had travelled. 4 Larvae are not usually submitted to the LSPQ as part of passive surveillance because they tend to bite small animals and rarely humans. 5 Two of the four local services networks targeted by this measure were transferred to the health region of Estrie when the Centre intégré universitaire de santé et de services sociaux de l’Estrie – Centre hospitalier universitaire de Sherbrooke was created in April 2015. Report on Surveillance for Lyme Disease: 2016 4 The literature indicates that an increased number of the most multiple submissions in 2016, while in 2015, it I. scapularis nymphs submitted from passive surveillance was Montréal (n = 14), Outaouais (n = 9), Laval (n = 7) was associated with an increase in the number of human and Mauricie et Centre-du-Québec (n = 7) that sent the cases in the State of Maine in the United States (Rand et greatest number of multiple submissions.